Jae-Hwi Nho

Retaining well-fixed cementless stem in the treatment of infected hip arthroplasty

Background and purpose Two-stage reconstruction, reimplantation after removal of an infected prosthesis, has been considered to be the gold standard for treatment of infected hip arthroplasty. However, during the removal of a well-fixed femoral stem, the proximal femur can be damaged and a sequestrum can be formed, which might lead to chronic osteomyelitis and difficulty in reimplantation. We wanted to determine whether infection after hip arthroplasty can be treated without removal of a well-fixed stem. Methods We treated 19 patients who had an infection after hip replacement, but a well-fixed cementless stem, with 2-stage reconstruction. At the first stage, we removed the acetabular cup, the liner and the head, but not the stem. We then implanted a cup of cement spacer. After control of infection, we reimplanted the acetabular component and head. Results 2 patients did not undergo second-stage reconstruction because they were satisfied with the pain relief and the activity that they had with the cement-spacer implantation. The remaining 17 patients underwent the second-stage of the reconstruction using cementless arthroplasty. At a mean follow-up time of 4 (2–8) years, 15 of the patients had no recurrence of infection, with satisfactory clinical and radiographic outcome. Interpretation This second-stage reconstruction after retention of the stem could be an alternative treatment option for periprosthetic infection with a well-fixed stem.

National Trends of Surgical Treatment for Intertrochanteric Fractures in Korea

Intramedullary nailing has been reported to have better outcome compared with traditional plate fixation in surgical treatment of intertrochanteric fractures. We evaluated the trends of surgical treatment of intertrochanteric fracture in Korea. Data of patients with intertrochanteric fractures, who were operated between the years of 2006 and 2011, was obtained from the Health Insurance Review and Assessment Service. The ratio of intramedullary nailing increased from 27.9% in 2006 to 64.3% in 2011 (P < 0.001), while the ratio of plate fixation decreased. During recent 5 yr, the utilization of intramedullary nailing doubled in clinical practice of intertrochanteric fractures in Korea.

Examination of the Pronator Quadratus Muscle during Hardware Removal Procedures after Volar Plating for Distal Radius Fractures

Background It is not clear whether the pronator quadratus (PQ) muscle actually heals and provides a meaningful pronation force after volar plating for distal radius fractures (DRFs). We aimed to determine whether the length of the PQ muscle, which is dissected and then repaired during volar plating for a DRF, affects the forearm rotation strength and clinical outcomes. Methods We examined 41 patients who requested hardware removal after volar plating. We measured the isokinetic forearm rotation strength and clinical outcomes including grip strength, wrist range of motion, and disabilities of the arm, shoulder and hand (DASH) scores at 6 months after fracture fixation. During the hardware removal surgery, which was performed at an average of 9 months (range, 8.3 to 11.5 months) after fracture fixation, we measured the PQ muscle length. Results The average PQ muscle length was 68% of the normal muscle length, and no significant relationship was found between the PQ muscle length and the outcomes including isokinetic forearm rotation strength, grip strength, wrist range of motion, and DASH scores. Conclusions This study demonstrates that the length of the healed PQ muscle does not affect isokinetic forearm rotation strength and clinical outcomes after volar plating for DRFs. The results of this study support our current practice of loose repair of the PQ that is performed by most of the surgeons to prevent tendon irritation over the plate, and suggest that tight repair of the PQ is not necessary for achieving improved forearm function.

Ceramic Head Fracture in Ceramic-on-Polyethylene Total Hip Arthroplasty

Revision rates of total hip arthroplasty have decreased after introducing total hip arthroplasty (THA) using ceramic component, since ceramic components could reduce components wear and osteolysis. The fracture of a ceramic component is a rare but potentially serious event. Thus, ceramic on polyethylene articulation is gradually spotlighted to reduce ceramic component fracture. There are a few recent reports of ceramic head fracture with polyethylene liner. Herein, we describe a case of a ceramic head component fracture with polyethylene liner. The fractured ceramic head was 28 mm short neck with conventional polyethylene liner. We treated the patient by total revision arthroplasty using 4th generation ceramic on ceramic components.

Posterior shoulder dislocation with ipsilateral proximal humerus type 2 physeal fracture: case report.

In pediatric patients, proximal humeral physeal fractures are uncommon injuries compared with distal physeal fractures. Usually, the growth plate is the most vulnerable site of fracture in the proximal humerus. Proximal humeral physeal fractures accompanying posterior shoulder dislocation are very rare. There are few recent reports on the combination of glenohumeral dislocation and proximal humerus fractures. Here, we describe a case of posterior shoulder dislocation with ipsilateral proximal humerus type 2 physeal fracture in a 9-year-old boy. We treated the patient by closed reduction and percutaneous pinning under general anesthesia.

Clinical and Radiologic Outcomes among Bipolar Hemiarthroplasty, Compression Hip Screw and Proximal Femur Nail Antirotation in Treating Comminuted Intertrochanteric Fractures

Purpose In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty (BH), compression hip screw (CHS) and proximal femur nail antirotation (PFNA) in treating comminuted intertrochanteric fractures (AO/OTA classification, A2 [22, 23]) Materials and Methods We retrospectively evaluated total 150 patients (BH, 50; CHS, 50; PFNA, 50) who were operated due to intertrochanteric fractures from March 2010 to December 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris Hip Score, mobility (Koval stage), visual analogue scale and radiologic limb length discrepancy (shortening). Results There was no statistical significance among three groups in clinical outcomes including Harris Hip Score, mobility (Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively (radiologic shortening: BH, 2.3 mm; CHS, 5.1 mm; PFNA, 3.0 mm; P=0.000). Conclusion There were no clinical differences among BH, PFNA, and CHS in this study. However, notable limb length shortening could be originated during fracture healing in osteosynthesis, compared to arthroplasty (BH

Management of Blood Loss in Hip Arthroplasty: Korean Hip Society Current Consensus

The volume of hip arthroplasty is stiffly increasing because of excellent clinical outcomes, however it has not been shown to decrease the incidence of transfusions due to bleeding related to this surgery. This is an important consideration since there are concerns about the side effects and social costs of transfusions. First, anemia should be assessed at least 30 days before elective hip arthroplasty, and if the subject is diagnosed as having anemia, an additional examination of the cause of the anemia should be carried and steps taken to address the anemia. Available iron treatments for anemia take 7 to 10 days to facilitate erythropoiesis, and preoperative iron supplementation, either oral or intravenous, is recommended. When using oral supplements for iron storage, administer elemental iron 100 mg daily for 2 to 6 weeks before surgery, and calculate the dose using intravenous supplement. Tranexamic acid (TXA) is a synthetic derivative of the lysine component, which reduces blood loss by inhibiting fibrinolysis and clot degradation. TXA is known to be an effective agent for reducing postoperative bleeding and reducing the need for transfusions in primary and revision total hip arthroplasties. Patient blood management has improved the clinical outcome after hip arthroplasty through the introduction and research of various agents, thereby reducing the need for allogeneic blood transfusions and reducing the risk of transfusion-related infections and the duration of hospitalizations.

Closed rupture of flexor tendon by hyperextension mechanism in wrist level (zone V): a report of three cases

Closed flexor tendon ruptures due to trauma without external wound are rare. When the flexor tendon has excessive loading, failure occurs at the tendon insertion or its origin from the bone. It is likely to result in avulsion fracture rather than rupture of the proper portion of the tendon by forceful grasping with hyperextension. However, we have experienced three cases of closed flexor tendon ruptures at zone V, caused by forceful grasping or hyperextension mechanism against resistance. On physical examination, these patients could not flex interphalangeal joint of thumb or distal interphalangeal joint of the fifth finger. All patients underwent MRI or ultrasonography to find out the location of loss in continuity of the flexor tendons before the operation. After identifying the location, flexor tendon repair or tendon graft using palmaris longus were performed.

Pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B: A case report

Rationale: We report a case of a hepatitis B virus (HBV)-positive patient with preexisting bone disease who developed tenofovir-induced Fanconi syndrome and subsequently sustained pathologic fracture. To our best knowledge, this is the first report in the English literature about pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B (CHB). The present report describes detailed our experience with the diagnosis of pathologic femoral fracture due to tenofovir-induced Fanconi syndrome and treatment. Patient concerns: A 45-year-old man visited our hospital with pain in the right thigh region and gait disturbance which had started 3 months ago and worsened 1 week before admission. The patient was diagnosed with CHB in 2004. He was on lamivudine medication for 2 years. Medication for the patient was subsequently changed to adefovir in 2009 and tenofovir disoproxil fumarate (TDF) in 2013. He was on TDF since 2013. Diagnosis: His hip joint magnetic resonance imaging (MRI) revealed hypointensity lesions and cortical bone destruction in fat-saturated MR image at the iliopsoas muscle attachment site of the lesser trochanter of both femur. On blood test showed 25-OH vitamin D level at 6.42 ng/mL (normal range, >20 ng/mL) and U-deoxypyridinoline level at 7.60 nM/mMcr (normal range, 2.30–5.40 nM mMcr). However, osteocalcin and parathyroid hormone levels were within normal range. Based on these findings, the present case was concluded as tenoforvir-induced Fanconi syndrome. Interventions: TDF treatment was discontinued. After cooperation with internal medicine department, in order to prevent further fractures of the right lesser trochanter, internal fixation was performed under spinal anesthesia using compression hip nails (APIS, TDM, Korea). Outcomes: Positive outcome by medication and operation demonstrates that his phosphorus and serum calcium levels were maintained within normal range and pain in the right thigh region was improved from visual analogue pain score (VAS) 7 before surgery to VAS 2 after surgery. Lessons: Physicians need to regularly monitor bone metabolism in patients with take in tenofovir for early diagnosis before its progression to pathologic fractures.

Low Positive Predictive Value of Bone Scan to Predict Impending Complete Fracture among Incomplete Atypical Femoral Fracture

Background Although bone scan might be useful to detect incomplete atypical femoral fractures (AFFs) earlier than radiographs, there is no study on predicting further progression to a complete fracture among incomplete AFFs. Our purposes are to determine whether bone scan detects impending complete fracture among incomplete AFFs. Methods We reviewed 18 patients (20 AFFs) who underwent bone scan at the diagnosis of incomplete AFF and were not treated with prophylactic fixation. A diagnosis of impending complete fracture was made, when the femur completely fractured within 6 months after the scan. We correlated radioisotope uptake with the impending complete fracture to calculate sensitivity, specificity, positive predictive value and negative predictive value of bone scan. Results Thirteen AFFs (65%, 13/20) showed a positive uptake in bone scan. Among the 13, only one femur was completely fractured within 6 months. None of the 7 femurs without uptake in bone scan fractured. In diagnosing impending complete fracture, the sensitivity of bone scan was 100% and negative predictive value was 100%. However, the specificity (36.8%) and positive predictive value (7.7%) were quite low. Conclusion Bone scan has no significant role in detecting the impending complete fracture, and a positive uptake does not mean the necessity of prophylactic fixation of incomplete AFF.